Authors: Bai Y-X et al.
Journal of Clinical Anesthesia, 2026, Article 112161
This international multicohort study evaluated whether target-controlled infusion (TCI) improves postoperative recovery compared to manually controlled infusion (MCI) in elderly patients undergoing cardiac surgery.
TCI uses pharmacokinetic models to maintain targeted plasma concentrations of anesthetic agents, allowing more precise titration compared to traditional manual infusion. While its physiologic advantages are well known, its impact on meaningful postoperative outcomes has been less clear—especially in high-risk elderly cardiac patients.
In this large retrospective study of nearly 1,400 patients aged 65 and older, TCI and MCI groups were matched using propensity scoring and analyzed across two independent cohorts. The primary outcome was ICU length of stay, with secondary outcomes including reintubation, acute kidney injury (AKI), mortality, and intraoperative hemodynamic stability.
The results consistently favored TCI. Patients receiving TCI had significantly shorter ICU stays, with reductions of approximately 1 day across both cohorts. TCI was also associated with lower rates of reintubation, reduced AKI, and a signal toward decreased in-hospital mortality in the primary cohort. These improvements were supported by findings in the validation cohort, particularly for ICU stay and respiratory outcomes.
A major differentiator was intraoperative hemodynamic stability. Although the incidence of hypotension itself was similar between groups, TCI significantly reduced blood pressure variability and the overall burden of hypotension. This was demonstrated through lower variability indices and smaller areas under MAP thresholds, suggesting more controlled and consistent perfusion during surgery.
The physiologic implications are important. Reduced variability and hypotension burden are strongly associated with decreased end-organ injury, particularly renal dysfunction and postoperative respiratory failure. Additionally, the precision of TCI likely reduces anesthetic overdosing and drug accumulation, contributing to faster emergence and improved respiratory recovery.
Subgroup analysis suggested that patients with lower BMI may derive even greater benefit from TCI, though most other subgroups showed consistent effects. Sensitivity analyses confirmed that these findings were robust across different time periods and modeling approaches.
Limitations include the retrospective design and potential residual confounding despite matching. Differences in institutional practice patterns and familiarity with TCI may also influence results. Nonetheless, the consistency across two independent datasets strengthens the overall conclusions.
Key Points
- TCI improves intraoperative hemodynamic stability by reducing variability and hypotension burden
- Associated with shorter ICU stays (approximately 1 day reduction)
- Lower rates of reintubation and acute kidney injury
- Signal toward reduced in-hospital mortality
- Benefits consistent across international cohorts
What You Should Know
This study reinforces that precision anesthesia delivery has real clinical consequences. TCI is not just about smoother numbers on the monitor—it translates into better recovery for high-risk cardiac patients. In an elderly population where even small physiologic insults matter, reducing blood pressure swings and anesthetic variability appears to improve outcomes. If your practice is not routinely using TCI for cardiac cases, this is strong evidence that it should at least be seriously considered.
We want to thank the Journal of Clinical Anesthesia for allowing us to summarize and share this important work with the anesthesia community.